Care risk assessment failures
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
2,106 items
13 sources
6 inquiries
Source spread
Where this theme appears
Care risk assessment failures has been flagged across 13 independent accountability sources:
16 inquiry recs
151 PFD reports
11 committee recs
374 CQC actions
2 HMICFRS recs
6 PPO recs
1 IOPC rec
1 IMB report
13 IMB recs
4 Article 2 learning points
32 PHSO decisions
1491 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (16)
R25 — Pressure damage risk assessment
Recommendation: Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score.
Gov response: Section 4.1 of the Scottish Government's response addresses this by stating that the prevention and management of pressure ulcers is a fundamental aspect of nursing practice. Healthcare Improvement Scotland published a Best Practice Statement - …
Accepted
POH-14 — Post Office to engage in negotiations during HSSA appeal period
Recommendation: During the nine-month period afforded to claimants to submit an appeal to the Department in HSSA, the Post Office shall engage in negotiations and/or mediation with any claimants who notify the Post Office of a desire to seek a negotiated …
Gov response: Department for Business and Trade accepts this recommendation. Rather than a 9-month period, DBT has implemented a 3-month notification deadline for claimants to indicate their intent to appeal, with subsequent deadlines for submission of full …
Accepted
POH-12 — Amend GLOS to allow claimants oral submissions at panel hearings
Recommendation: The scheme documents governing GLOS should be amended so that a right is conferred upon claimants (exercisable by the claimants themselves or their recognised legal representatives) to make oral submissions in support of their claim at the hearing convened by …
Gov response: Department for Business and Trade accepts this recommendation. GLOS claimants already had the right to make oral submissions for up to one hour at independent panel hearings prior to the panel making a binding determination. …
Accepted
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool.
Gov response: Section 4.1 of the Scottish Government's response acknowledges the report's criticisms of specific elements of nursing care, including the unsatisfactory assessment and recording of patients' nutritional status. The government unreservedly accepts in full the report's …
Accepted
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
SP22 — LCC online harms risk assessment review
Recommendation: Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms to children. This review should ensure that all frontline staff …
Response Pending
SP2 — Shared multi-agency risk-assessment tool
Recommendation: Phase 2 should consider the development of a shared multi‑agency risk‑assessment tool that is clear, accessible and suitable for use across public sector services.
Response Pending
WATE-(46) — Prohibit emergency admissions to all private residential schools
Recommendation: Emergency admissions should not be made to private residential schools.
Unknown
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
JB-15.4 — Amend firearms authorisation forms for risk assessment and tipping points
Recommendation: There should be an amendment to FA (and equivalent) forms to: a. encourage a multidimensional risk assessment (to comply with Article 2) to minimise, to the greatest extent possible, recourse to lethal force; b. include a provision for reference to …
Gov response: MPS formally responded on 28 October 2022 (paras 12-14). Internal guidance issued to CTSFO Tac Advisors within MO19 on tailoring FA5 forms. Training time set aside for FA form usage and completion.
Accepted
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
R7 — Reorganisation due diligence
Recommendation: In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the Board or Boards responsible.
Gov response: Section 2.2 of the Scottish Government's response describes the 'Governance for Quality Healthcare in Scotland - an Agreement' and a 'clinical and care governance framework for integrated health and social care services' to ensure good …
Accepted
JB-15.2 — Require multidimensional risk assessments throughout operations
Recommendation: Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and risk at all stages of the operation.
Gov response: MPS formally responded on 28 October 2022 (paras 7-8). Firearms trainers required to watch Inquiry hearing recordings. Particular focus now on multidimensionality at all stages of operational planning. MO19 supporting College of Policing on improved …
Accepted
PFD Reports (151) — showing 50 strongest matches
Derek Edward Bartlett Twivey
Concerns: The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be taken to prevent such occurrences.
Overdue
Annie Rose Gibson
Concerns: The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after a client fall.
Overdue
May Gibson
Concerns: The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, and implementing risk reduction plans at the care home.
Overdue
Peter Pattinson
Concerns: Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Response (European Care Group): The care group has implemented new bed rail risk assessment and checking systems, along with staff training on safe bed rail usage. They also numbered daily statement documents to prevent …
Responded
George Renshaw Brown
Concerns: A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to more suitable accommodation.
Overdue
John William Tugwell
Concerns: The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Overdue
Derrick Plater
Concerns: There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Response: The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and …
Responded
Ernest Harper
Concerns: Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Response (Bedford Borough Council): Bedford Borough Council has retro-fitted devices to block gaps on Ford Transit vehicles. A new assessment form designed with Occupational Therapists will be introduced by July 14, 2014, and a …
Responded
Ross Boyd
Concerns: An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Response (Milton Keynes Council): Milton Keynes Council reviewed the case and believes the placement was appropriate given the information available at the time. They will ensure managers discuss the use of respite beds with …
Pending
Harold de Mello
Concerns: A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care needs, or consult relevant family.
Response (Tower Hamlets Local Authority): Tower Hamlets Social Services has convened a Case Review meeting and commissioned an internal management review. They are developing a risk analysis tool, introducing an eco-mapping tool, and scheduling targeted …
Responded
Elaine Jobe
Concerns: The report cites inadequate record keeping related to risk assessments and observation levels, a lack of training records for staff on risk assessment and observation implementation, and the need to review communication of patient status among staff.
Response (Devon Partnership NHS Trust): Devon Partnership NHS Trust has reviewed their policies and plans to complete additional actions, including reviewing risk assessments and delivering ward-based training on the updated policy, by January 2015. They …
Responded
Charles Lawrence
Concerns: The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.
Response (Alexandra Rose Residential Care Home): The care home implemented a 'falls alert' notification to be faxed to residents' doctors after more than one fall in 24 hours, and included this protocol in resident care plans.
Responded
Edna Bulmer
Concerns: The coroner noted inconsistencies in the documented level of falls risk and that measures to minimise risk were not implemented promptly. It was also unclear whether a system was in place for reviewing risk assessments after further incidents.
Overdue
Derek Hawkins
Concerns: The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify increased risks.
Overdue
Darren Hayes
Concerns: Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk individual. Key external health providers were also not contacted for assistance.
Response (Norfolk County Council): Norfolk County Council has taken action regarding the individual worker involved and the Adult Social Services Quality Assurance Team is developing a Best Practice factsheet to formalise local custom and …
Responded
George Hulme
Concerns: Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and incorrect patient file retrieval for treatment.
Overdue
Maria Silkin
Concerns: The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to a dangerous delay in appropriate medical intervention.
Overdue
Thomas Taylor
Concerns: The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.
Overdue
Emmeline Hampson
Concerns: Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and a lack of agency staff training were also concerns.
Overdue
Howell Fisher
Concerns: Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.
Overdue
Ian Morley
Concerns: A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Overdue
John Lomas
Concerns: Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication between organisers and the Army contributed to the death.
Response (Sport Camp Tirol): Sport Camp Tirol disputes several factual points in the coroner's report, asserts its guides acted appropriately, and blames the army for allowing a non-swimmer on the trip. It will require …
Responded
Peter Furness
Concerns: The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Response (Nant Y Gaer Hall): Nant Y Gaer Hall has implemented a new alert system for changes in residents' conditions, with training and supervision for staff. The new system includes forms, flow charts, and posters, …
Responded
Peter Buckle
Concerns: An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite training.
Response: Wayland Farms implemented new health and safety programs including a behavioral safety training program ('stop and think'), and will provide further training with external consultant input. They acknowledge the need …
Responded
David White
Concerns: Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and these notes were not reviewed or acted upon.
Response: Staff have been reminded of the importance of documenting allergies and adverse effects, including in Renal Mortality and Morbidity meetings; the safety briefing during nursing handover will now include care …
Responded
Alan Ludlow
Concerns: Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes being unaware of vital safety history for vulnerable individuals.
Overdue
Joanna Bowring
Concerns: Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Response (Joanna Bowring): The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments …
Responded
Marjorie Wood
Concerns: There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care and treatment.
Response (Kingsley Healthcare Group): Kingsley Healthcare Group has reviewed its Deprivation of Liberty Safeguards Policy and Procedure and has provided further training and supervision to staff and checked for completed application and authorization records …
Overdue
Freda Cordy
Concerns: A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Overdue
Micael McMonigle
Concerns: Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and the response to the patient's absence was delayed and did not conform with procedures; staff knowledge of leave policy was inadequate.
Overdue
Maureen Flynn
Concerns: A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Response (Stockport NHS Trust): The Trust has completed actions detailed in an updated Patient Safety Investigation report, including an audit of falls risk assessments, enhanced falls sensors, and sharing investigation findings via ward newsletters, …
Responded
Demi Williams
Concerns: Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.
Overdue
Dorethea Parr
Concerns: Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.
Response (Cornwall Partnership NHS Trust): Cornwall Partnership NHS Trust has embedded a policy to deal with slips, trips and falls in the community, requiring staff to complete risk assessments and incident reports, and intends to …
Responded
Raymond Shepherd
Concerns: Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or a mental capacity assessment.
Response (Human Support Group): The Human Support Group has implemented several changes including revising the care planning process, incorporating falls prevention information into training, developing a falls poster, reviewing care planning matrix, and adding …
Overdue
David Cooper
Concerns: Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.
Response: The University Health Board established a Falls Management Group, reviewed policies and training requirements, introduced National Patient Safety Agency's Risk Assessments, devolved falls management to Directly Managed Units, and will …
Overdue
Roger Tombs
Concerns: Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Response (Sunrise Senior Living): Sunrise Senior Living acknowledges the report but states it is leaving the Home's management and registration with CQC on 1 March 2017. It invites dialogue and can describe immediate actions …
Response (Roger Tombs): The Falls Team reviewed its practices after the PFD report and found them consistent and accurate. A guidance document outlining good practice in sensor mat use was developed and sent …
Overdue
Etheline De-Gale
Concerns: Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Response (Response Ambassador House Home): Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at …
Responded
Patrick Woods
Concerns: The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.
Response (Draeger Medical UK Limited): Draeger Medical UK has updated its training documentation, including the Basic Skills Checklist and powerpoint presentation, to address the use of the ACGO switch and relevant ventilation modes. They are …
Response (Luton Dunstable University Hospital): Luton and Dunstable University Hospital has reconfigured default alarm settings on anaesthetic machines, educated staff on unused functionality, and implemented a system to manage medical equipment logs. The Clinical Director …
Overdue
Sheila Hynes
Concerns: A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
Overdue
Patricia Norfolk
Concerns: Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.
Overdue
John Ramsden
Concerns: Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Overdue
Cameron Chadwick
Concerns: A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.
Response (Wigan Council): Following the report, the council measured the pothole depth and repaired it, both temporarily and permanently. They assert this was done despite the pothole not meeting the threshold for intervention …
Responded
Rose Workman
Concerns: The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.
Response (Rose Workman): The district nursing service employs measures to ensure that patients are effectively monitored of their ongoing conditions, and the electronic clinical patient record "SystmOne" has undergone extensive re-engineering, launched in …
Responded
Robert Cardwell
Concerns: Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Overdue
Constance Connolly
Concerns: The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they ordered, and a breakdown in communication between different care teams resulting in a cancelled appointment and no further action.
Response (The Royal College of Emergency Medicine): The Royal College of Emergency Medicine has issued guidance to Fellows and Members regarding follow-up of test results in two documents, and is preparing a safety alert reminding them to …
Response (King's College Hospital NHS Foundation Trust): King's College Hospital NHS Foundation Trust is setting up a "virtual review" of self-discharged patients to ensure any investigations or follow-ups can be appropriately actioned.
Responded
Lesley Hanson
Concerns: Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.
Response (Welsh Government): Since the death, codes of practice to assess and meet the needs of individuals with care and support needs have been issued which underpin the Social Services and Well-being (Wales) …
Response: The council has reviewed processes resulting in improvements to policy regarding suitability of stairs and stair-gates in supported accommodation schemes. A new referral form, stair assessment tool and training has …
Responded
Maya Kantengule
Concerns: Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments for swimming pool birthday parties, and failures to follow safety procedures, including non-functional CCTV.
Response (Waveney River Centre): Following the incident, the Waveney River Centre no longer hires its pool for swimming parties. Staff formal safety training courses such as IOSH have been arranged.
Responded
John Lambton
Concerns: Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.
Overdue
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Response: The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health …
Overdue
Stanley Langdon
Concerns: A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Response (Haven Day Centre): The Haven Day Centre implemented all suggested improvements from a County Durham Commissioning team report, including obtaining signatures on risk assessments, reviewing complaints policies, unifying transport policies, improving training records, …
Overdue
Committee Recommendations (11)
#7 — Inadequate assessment of mental health for children and young people in care.
Recommendation: Young people in care are significantly more likely to have experienced trauma and adverse experiences than their peers, and therefore strong mental health support is crucial. Although local authorities are required to assess the emotional and mental health of children …
Gov response: Government response to Conclusion six: We know that provision of effective support, including mental health support, is crucial for children in care and care leavers. Regulations and statutory guidance already clearly stipulate requirements for assessment …
Accepted
#56 — Address inappropriate assessment processes for disabled children’s parents and implement Law Commission proposals.
Recommendation: It is deeply concerning to hear that parents of disabled children are being treated with suspicion and undergoing inappropriate assessment processes when reaching out for help. The Department for Education must address this as an urgent priority and ensure that …
Gov response: As set out in the protocol between the Lord Chancellor and the Law Commission, a Department for Education Minister will provide an interim response to the Commission as soon as possible and in any event …
Not Addressed
#6 — Update Code of Guidance and end family placements sharing facilities with single adults.
Recommendation: We are alarmed to hear examples of families housed in temporary accommodation that included spaces shared with single adults with a history of domestic abuse. This is completely inappropriate and poses a potential safeguarding risk to children. Currently, there is …
Gov response: 22. Local authorities are already required to report to the Ministry of Housing Communities and Local Government (MHCLG) on instances of out of area placements as part of their quarterly Homelessness Case Level Information Collection …
Under Consideration
#3 — Mandate local authorities to conduct mandatory temporary accommodation inspections and publish annual reports.
Recommendation: Some local authorities are not taking sufficient account of the needs of children and families when making decisions on temporary accommodation placements. Many local authorities do not carry out any regular inspections of the conditions in the accommodation they use …
Gov response: 15. Current legislation is very clear that B&B accommodation is not suitable for children and should only be used in emergencies and then only for a maximum of six weeks. B&B accommodation is privately managed, …
Not Accepted
#22 — CCRC leadership underestimates risks and impact of operating without full commissioner quota.
Recommendation: Karen Kneller told us that the “validity of the work of the CCRC or any decision taken is not impacted by commissioner numbers”. We question this assertion. Operating without a full quota of commissioners, in other words ‘short-staffed’, must place …
Gov response: The report concludes that the amount of time taken to recruit Commissioners, and agree fee levels, is concerning. As noted in paragraph 18, the public appointment process to recruit Commissioners requires consultation at several stages. …
Not Addressed
#1 —
Recommendation: We conclude, in line with our report on Social care: funding and workforce, the current social care system is “unfair and confusing”. Those living with dementia remain unprotected from unlimited costs and navigating the system is burdensome for those providing …
No Published Response
#18 — Home Office still developing specific safety measures for residents in large accommodation sites.
Recommendation: The Home Office is responsible for the safety and wellbeing of people in its care, whether they are claiming asylum or pending relocation. But the National Audit Office reported that, in January 2024, the Home Office was still developing specific …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 All individuals are able to raise concerns with the department whilst their case is under consideration and where safeguarding concerns are raised, these are …
Accepted
#1 — Persistent appalling conditions in temporary accommodation gravely endanger children's health and wellbeing.
Recommendation: The appalling conditions in some temporary accommodation in England are utterly shameful. We are concerned that issues of poor-quality temporary accommodation continue to persist, even though it is now over five years since the then Children’s Commissioner described these conditions …
Gov response: 11. There are legal requirements, guidance and redress routes in place for temporary accommodation. 12. We are already taking action on the issues raised by this recommendation. Through the Renters’ Rights Bill the Government is …
Accepted
#11 — Site-specific viability assessments frequently reduce affordable housing requirements unjustifiably.
Recommendation: Too often, site-specific viability assessments are used by developers to negotiate down affordable housing requirements in circumstances where this is completely unjustifiable. Affordable housing contributions are frequently the first provision to be cut following a viability assessment, even where a …
Gov response: 59. A full Government response to the New Towns Taskforce’s report is planned for Spring 2026 which will contain more information on financing models. Each location will have differences in size, geography and infrastructure needs …
Under Consideration
#14 —
Recommendation: Shortly after starting on the Restart scheme, participants undertake a ‘diagnostic assessment’ with providers, to understand the extent to which things like the physical and emotional demands of work, travel, literacy, numeracy, debt, housing, criminal convictions, and family life challenges …
Gov response: 3. PAC conclusion: The Department and providers are not working together and sharing information as effectively as they might to support participants into work. 3a. PAC recommendation: The Department should ensure work coaches and Restart …
Accepted
#7 —
Recommendation: As its understanding of the disease has grown, DHSC has developed a new risk assessment tool, QCovid, to identify people at risk based on wider factors which make them at more risk from COVID-19. DHSC described the tool as having …
Gov response: 1.2 Shielding is an intervention to protect the clinically extremely vulnerable to reduce risk of severe illness or death. It is, therefore necessarily linked to susceptibility to disease. Shielding support was put in place to …
Not Addressed
CQC Inspection Actions (374) — showing 50 strongest matches
Dalwood FarmHouse
The registered manager had not ensured risks to the health, safety and welfare of people who use the service were assessed and kept under review.
Must Do
Cotton Exchange
The provider must assess, monitor and mitigate the risks relating to the health, safety, and welfare of service users.
Must Do
Cotton Exchange
The provider must have processes that assess the risks to the health and safety of service users receiving the care or treatment.
Must Do
Continuity Healthcare Services Private Limited
The provider did not adequately assess and protect people against risks by doing all that was practicable to identify and mitigate such risks. The provider did not ensure staff had adequate qualifications, competence and skills to provide safe care. The …
Must Do
Clova House Residential Care Home
The provider agreed that they would not only risk assess this area but look at how they could reduce any potential risk to people who used the particular bedrooms.
Must Do
Baby Bump Limited
The service must provide care and treatment in a safe way and must appropriately assess the risks to the health and safety of service users receiving the scans.
Must Do
We Can Recover CIC
The admission process was unsafe, in that staff who screened client’s admission and risks were not trained to do so. The process for reviewing risk prior to admission was unclear. Staff screening client’s admission had not completed all the role …
Must Do
Trent Lodge Residential Care Home
The registered person must ensure that each service user is protected against the risks of receiving care and treatment that is inappropriate or unsafe by means of the effective operation of systems designed to enable the registered person to identify, …
Must Do
Reside at Southwood
The provider must ensure that risks to the health and safety of people are assessed and steps to mitigate the risks are taken, that the premises and equipment is safe to use and is used in a safe way, that …
Must Do
Pennsylvania House
The provider must ensure people who use services are protected against the risks of receiving unsafe or inappropriate care by documenting risks to people and having a plan to manage these risks.
Must Do
Nower House
The failure to ensure risks to people's safety were robustly monitored and that safe medicines systems were followed was a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Laurel Lodge Care Home
The provider must ensure that all reasonable steps are taken to ensure the risks to people are minimised.
Must Do
Kingsleigh Residential
The provider had failed to ensure risks to people were mitigated.
Must Do
Ashcroft House - Leeds
The provider had failed to robustly assess the risks relating to the health safety and welfare of people and had failed to ensure the proper and safe management of medicines.
Must Do
Arthur House
People were not protected from harm due to inadequate risk management processes within the service.
Must Do
Arthur House
The provider did not have consistent effective systems in place to assess and monitor risks relating to the health, safety and welfare of people using the service.
Must Do
Archers Point Residential Home
Risks were not always assessed, and risk management plans were not always in place to manage these safely.
Must Do
Yanah Care
The provider must ensure effective systems and processes are in place to ensure care and treatment is provided in a safe way to people.
Must Do
Woodbridge Lodge Residential Home
The systems in place were not robust enough to reduce the risks of people receiving unsafe care.
Must Do
Wishingwell Residential Care Home
The provider had not assessed risks and done all that is reasonably practicable to mitigate risks; they had not ensured the safe management of medicines. Regulation 12(1).
Must Do
Westwood Care Home
The provider had not taken adequate steps to ensure safety risks, and incidents and accidents were assessed and mitigated. The provider had not ensured there was adequate governance of medicine administration or that staff competency was up to date.
Must Do
Walfinch West Suffolk
The provider must ensure their systems are in place and robust enough to demonstrate risks to people's safety, including the review of care and risk management planning, are effectively managed.
Must Do
Utmostcare Limited
Risks to people were not clearly identified and managed. Risk assessments were either not present or lacked sufficient detail to help staff understand and respond to risks. The service had not ensured the proper and safe management of medicines, including …
Must Do
Unit 4 Cornishway Industrial Estate
Ensure they complete risks assessments doing all that is reasonably practicable to mitigate identified risks to patients.
Must Do
Unit 4 Cornishway Industrial Estate
Ensure they assess the risks to the health and safety of service of people usingservices. That risk assessments are available and completed by people with the qualifications, skills, competence and experience to do so.
Must Do
Two Trees Caring Home
The provider must ensure people who lived at the service are protected from risks of harm associated with their complex care needs.
Must Do
Threen House Nursing Home
The registered person did not ensure care and treatment was always provided in a safe way for service users.
Must Do
The Peter Gidney Neurodisability Centre
Risks to people were not always identified and did not detail how risks could be mitigated.
Must Do
The Old Post Office
The provider must establish systems to assess, monitor and mitigate the risks to people.
Must Do
The Old Post Office
The provider must ensure risks to people are fully identified and care is planned to keep people safe, and that medicines are managed in line with good practice.
Must Do
The Moat House
People were at risk of harm because systems were either not in place or robust enough to keep people safe and manage risks to their health and welfare effectively.
Must Do
The Long Brook Residential Home
Risks to people's health and safety had not been identified or mitigated.
Must Do
The Hailey Residential Care Home
The provider failed to assess the risks to the health and safety of service users and to do all that is reasonably practicable to mitigate risks.
Must Do
The Goddards
The provider must assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity.
Must Do
The Briars
Care and treatment was not provided in a safe way for service users because risk was not continually recognised or reviewed.
Must Do
TerraBlu Homecare
Registered persons had failed to adequately assess individual risks relating to the health, safety and welfare of people and staff.
Must Do
Stewton House Nursing Home
The provider must ensure systems and processes ensure people receive safe care and treatment and mitigate risks relating to people's health and safety.
Must Do
Stanford House
Effective systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.
Must Do
St Marks Residential Care Home
Systems had not been fully established to monitor and mitigate risks to the health, safety and welfare of people using the service. This placed people at potential risk of harm.
Must Do
St Albans House
The provider must assess risks to people and provide guidance to mitigate these risks. The provider must record and manage medicines safely.
Must Do
Spindrift Care Home Limited
Risk assessments and measures to reduce risks to people who lived at the home were not always up to date and reflective of people's current needs.The provider's business continuity plan was not up to date and required review. Personal Emergency …
Must Do
South Network
Risk assessments were not completed or were not reviewed. Regulation 12 (2) (a). The provider did not take reasonable steps to mitigate the risks to people who used the service. Regulation 12 (2) (b).
Must Do
Shenstone Hall Nursing Home
The provider must ensure that risk assessments and risk management plans are completed promptly for all people and kept up-to-date to ensure staff have the information needed to support people safely.
Must Do
Safe Sanctuary Living Ltd
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Must Do
Royal Manor Nursing Home
Risks were not always managed safely. There was a lack of oversight to ensure nurses were up to date with training and competent to provide safe care to people.
Must Do
Roky Care Ltd
The provider must ensure appropriate assessment of risks relating to the health and safety of service users receiving care and do everything reasonably practicable to mitigate any such risks.
Must Do
Reside at Stour Road
Systems and processes were not effective in monitoring and mitigating avoidable risks to people. People's records of their care and treatment were not always accurate or complete.
Must Do
Reside at Stour Road
Risks identified for people had not been consistently managed or actions taken in order to minimise the risks.
Must Do
Ransdale House
The provider must robustly assess the risks relating to the health, safety and welfare of people.
Must Do
Private Ultrasound Scan
The service must ensure that staff complete and update risk assessments for each patient.
Must Do
HMICFRS Recommendations (2)
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, chief constables should take steps to make sure that risk identification, assessment and management is effective in all stalking and breaches of orders cases, through screening tools, clear policies, recognition of breach risks, and screening processes …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: The inconsistent application of an effective THRIVE (threat, harm, risk, investigation, vulnerability and engagement) risk assessment by call handlers, accompanied by the absence of victim needs assessments and the limited extent to which repeat victims are identified …
Recommendation
PPO Death in Custody Recommendations (6)
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete the medical risk assessment in full, including signing and dating the form.
The Head of Healthcare
The Head of Healthcare should ensure that clinical checks on prisoners who are refusing food and/or fluids are carried out and recorded appropriately to ensure risks are managed.
The Governor
The Governor should ensure that before prisoners are located on B Wing, they are appropriately assessed to ensure they are vulnerable prisoners or are suitable to be housed with vulnerable prisoners.
The Governor
The Governor should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that authorising managers show that they have taken this information into account when assessing a …
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical …
The Governor
carry out fresh risk assessments for each escort when/if the prisoner’s condition changes to establish the appropriate level of restraints when travelling to and from hospital; and
IMB Recommendations (13)
Gatwick IRC/RSTHF (2022)
Ensure that relevant healthcare clinical staff, GPs and psychologists and psychiatrists are fully educated in the application of Rules 35(1) and 35(2) (section 4.4.2).
NHS / Healthcare Provider
Gatwick IRC/RSTHF (2022)
Building on the recommended review of AAR, ACDT and Rule 35, define and promulgate procedures and guidance to ensure cases of men “likely to be injuriously affected by continued detention” (Rule 35(1)) or who are suspected “of having suicidal intentions” (Rule 35(2)) are properly identified and assessed (section 4.4.2).
Home Office
Gatwick IRC/RSTHF (2022)
Undertake a complete review of Adults at Risk, ACDT and Rule 35 policy and procedure (repeated from 2019, 2020 and 2021) (section 4.4.1).
Home Office
Gatwick IRC (2024)
Review the mechanisms for informing and encouraging detained men to take up the offer of a Rule 34 appointment, as these are a vital safeguard, greatly increasing the likelihood of detection of vulnerabilities.
NHS / Healthcare Provider
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that all arrival interviews should be conducted in the purpose-built interview room in the facility, with privacy and with participants seated in comfort and speaking at eye level. We regard this recommendation is vital for safety as the purpose of the interview is to discover and identify risk factors relating to sensitive and personal circumstances such as whether …
Other
Gatwick IRC (2024)
Provide suitable training and support to ensure that all healthcare staff, including General Practitioners, are clear about their obligations under Detention Centre Rule 35, and understand how these are to operate.
NHS / Healthcare Provider
Gatwick IRC (2024)
Review how key mechanisms intended to safeguard the detained men operate together to ensure that they provide effective outcomes: Detention Gatekeeper, healthcare arrival screening, Rule 34 assessments, Rule 35 processes, assessment, care and teamwork in detention plans (ACDT, used to monitor detained people who are considered at risk of self-harm), ACDT and vulnerable adult care plan (VACP) processes, and Adults …
Home Office
North East Midlands, Yorkshire & Humber STHF (2024)
We ask for confirmation that the proposed actions on yellow hatching and pre-departure risk assessments have been implemented and are working satisfactorily (see section 4.2.1).
Other
Lowdham Grange (2024)
Prisoners who have not been recently sentenced are being transferred to HMP Lowdham Grange without a completed or up-to-date offender assessment (OASys). This means the assessment has to be completed at this prison, adding to pressure on the offender management unit (OMU) and putting prisoners at risk until it is completed. Does HMPPS feel it is acceptable that some establishments …
HMPPS
Gatwick IRC (2024)
Operate with a presumption of release in cases of vulnerability, considering not just whether vulnerabilities can be accommodated in detention, but also at what cost to the detained man.
Home Office
Gatwick IRC (2021)
As we have recommended for the past two years, there should be a full review of Adults at Risk (AAR), ACDT and Rule 35 policy and procedure (section 4.4).
Home Office
Swinfen Hall (2020)
A significant number of prisoners arrive at the establishment without a completed offender assessment system (OASys) assessment. This places an excessive demand on prison staff and causes prisoners considerable stress because they cannot embark on proper and safe sentence planning or make progress with rehabilitation; it also has an adverse impact on confidence in the prison regime. The issue has …
HMPPS
Swinfen Hall (2021)
What measures will be put in place to enable Swinfen Hall to continue to manage the increased number of prisoners arriving without a completed OASys assessment?
HMPPS
Health Investigations (4)
Independent investigation into the care and treatment of Mr L — Rec 1
The Trust must ensure that where a violent patient has been admitted to its services following concerns by other agencies; or complaints by neighbours about anti-social behaviour and noise and that they have been made aware of: • The risks are assessed appropriately • There are care plans developed to …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr L — Rec 4
The Trust must assure itself that risk assessments and risk management plans are reviewed when new information comes to light. The Trust must also implement an ongoing audit programme to provide assurance about organisational compliance with this requirement.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr L — Rec 4
The Trust must assure itself that risk assessments and risk management plans are reviewed when new information comes to light. The Trust must also implement an ongoing audit programme to provide assurance about organisational compliance with this requirement.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr L — Rec 1
The Trust must ensure that where a violent patient has been admitted to its services following concerns by other agencies; or complaints by neighbours about anti-social behaviour and noise and that they have been made aware of: • The risks are assessed appropriately • There are care plans developed to …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Accepted
Article 2 Learning Points (4)
— LP 3
I recommend that the Governor of HMP Ranby establishes: that the prison’s current practice complies with the requirement to check the OASys risk assessment of newly admitted prisoners and to inform their location of any identified risk of harm to self or others; and that residential staff at Ranby are …
The Governor (HMP Ranby)
— LP 2
The in-reach team should consider whether an algorithm based on risk presentation that is high, medium or low, would help to dictate time-frames for specific actions to be taken.
Central and North-West London NHS …
Accepted
— LP Healthcare 1
A range of information including that from assessment during custody and from court proceedings should be considered along with the presenting risk factors when undertaking an initial assessment of an individual’s risk of suicide/self-harm and the opening of a potential ACCT.
Healthcare Provider
— LP 4
I recommend that NOMS look into whether the requirement for early checking of OASys assessments for new prisoners is consistently observed in other prisons and consider whether further measures are necessary to ensure that the system is used and understood.
NOMS
PHSO Casework Decisions (32)
P-001435 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mr T raises various complaints about the care and treatment his mother, Mrs T, received at the Trust. Specifically, Mr T complains the Trust failed to follow the falls risk assessment completed for his mother, did not inform the family about her fall in a timely manner, did not send …
NHS in England
Upheld
Jun 2022
P-002496 — Gateshead Health NHS Foundation Trust
Ms A complains the Trust did not carry out appropriate nursing assessments of her father’s needs, failed to meet his continence needs and failed to assess his falls risk.
NHS in England
Upheld
Mar 2024
P-002541 — Royal Devon University Healthcare NHS Foundation Trust
Ms V complains the Trust did not properly assess her in A&E and did not provide follow-up or safety netting advice before sending her home.
NHS in England
Upheld
Apr 2024
P-002790 — Derbyshire Healthcare NHS Foundation Trust
Mrs A complains the Trust failed to recognise her son had a diagnosis of autism or that he was a vulnerable adult with a history of depression and self-harm. She says it did not take this seriously or into account when giving care and treatment and failed to give follow …
NHS in England
Jul 2024
P-003081 — A practice in the Rushcliffe area
Mr I and Mrs Y complain the Practice failed to appropriately assess their mother’s symptoms after she experienced a stroke on 16 January 2023.
NHS in England
Oct 2024
P-003303 — Manchester University NHS Foundation Trust
Mr G says the Trust failed to carry out appropriate assessments before discharging his father from hospital in December 2022 and because of this, his father was readmitted two hours later.
NHS in England
Jan 2025
P-003414 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs A complains the Trust did not appropriately monitor her brother, Mr Z, when he was undergoing Trial Without Catheter (TWOC), and did not respond adequately when he developed a life-threatening complication.
NHS in England
Mar 2025
P-003800 — West London NHS Trust
Mr L complains about the care his daughter received from West London NHS Trust. He complains about inadequate risk assessment and poor communication with his family.
NHS in England
Aug 2025
P-004776 — Leicestershire Partnership NHS Trust
Mrs E complains on behalf of her child, about Leicestershire Partnership NHS Trust (the Trust) in 2023. She says the Trust failed to provide trauma therapy, allocate a lead professional, conduct risk assessments, and provide care plan reviews.
NHS in England
Feb 2026
P-001261 — Barking and Dagenham, Havering and Redbridge Clinical Commissioning …
Mrs U complained about the CCG’s decision not to reimburse the advocate fees she paid while she was claiming retrospective continuing healthcare (CHC) costs for her mother.
NHS in England
Jan 2022
P-001270 — NHS England - North (regional office)
Mr I complained about the outcome of the Independent Review Panel (IRP) convened by NHS England, on 3 February 2020, to consider Greater Preston Clinical Commissioning Group’s (CCG) decision that his wife was not eligible for continuing healthcare funding (CHC) on 2 March 2016.
NHS in England
Jan 2022
P-002055 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs A complains the Trust failed to identify her mother as at risk of falling and left the bed rail on her bed down, causing her to fall out of bed.
NHS in England
Jun 2023
P-002404 — Sheffield Children's NHS Foundation Trust
Mrs B complains the Trust failed to properly assess and treat her son when he attended its emergency department. She also complains it discharged him despite his complex medical history.
NHS in England
Jan 2024
P-002566 — Guy's and St Thomas' NHS Foundation Trust
Mrs C complains about a consultant's decision to discharge her from orthopaedic care in March 2022. She says her concerns were not listened to and red flags were missed.
NHS in England
Apr 2024
P-002630 — A practice in the Sheffield area
Mrs L complains about different areas of the care and treatment the Practice gave to her husband between January 2022 and February 2023. She says it wrongly decided he did not have capacity, it did not monitor or follow up on his medication and it did not review him properly …
NHS in England
May 2024
P-003003 — East Sussex Healthcare NHS Trust
Miss A complains that clinicians failed to act on her mother’s high risk of falls in December 2022. She says her mother had two serious accidents and sustained significant injuries. Miss A also believes documentation was falsified.
NHS in England
Sep 2024
P-003080 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr A says the Trust discharged his wife from hospital in June 2023 when she was not fit to do so and without putting a care and support package in place.
NHS in England
Oct 2024
P-003088 — Mid and South Essex NHS Foundation Trust
Mrs D complains about her mother’s discharge from hospital. She says the Trust did not properly consider if her mother had capacity to decide if she wanted to go home, and it ignored her concerns about her mother’s safety.
NHS in England
Partly Upheld
Oct 2024
P-003391 — University Hospitals of North Midlands NHS Trust
Mrs A complains about the care and treatment the Trust gave her daughter, Miss B, when she was a hospital inpatient in October 2022. She says that given Miss B’s history of aspiration pneumonia the Trust should have done more to investigate the causes of her symptoms and whether they …
NHS in England
Mar 2025
P-003453 — Gateshead Health NHS Foundation Trust
Mrs H complains the length of time her niece had to wait to use the toilet after staff had given her an enema was wrong. She said this led to compartment syndrome. She also says the Trust did not do adequate care and risk assessments to keep her niece safe …
NHS in England
Partly Upheld
Mar 2025
P-003678 — Tees, Esk and Wear Valleys NHS Foundation Trust
Miss U complains that her daughter Miss R’s death was preventable and resulted from inadequate risk management, unsafe transition, poor communication, and repeated service failures between 10–12 January 2024.
NHS in England
Jul 2025
P-003758 — St George's University Hospitals NHS Foundation Trust
Mr G says the Trust failed to carry out appropriate investigations to diagnose his infant son and did not provide appropriate safety-netting advice.
NHS in England
Aug 2025
P-004322 — University Hospitals Birmingham NHS Foundation Trust
Mr A complains the Trust's falls management was poor, and it had a poor post‑incident response after his father fell in March 2023. He also complains there was a failing in the Trust's use of sedatives and the Trust imposed restrictions on his father without proper safeguards.
NHS in England
Nov 2025
P-004436 — Lancashire and South Cumbria NHS Foundation Trust
Mr A complains about the standard of care and treatment his mother received from the Trust from November - December 2020.
NHS in England
Upheld
Nov 2025
P-001570 — Mid and South Essex NHS Foundation Trust
Ms C complains the Trust did not closely watch her father. She says it knew he was agitated and he had taken off his oxygen mask before. She feels the Trust should not have left him in an isolated room where it was difficult for him to call for help. …
NHS in England
Oct 2022
P-002281 — North West Ambulance Service NHS Trust
Mr U complains the Trust failed to transport his mother to hospital several times between August and October 2021. He says the failed transport attempts were because the Trust did not carry out a risk assessment on his mother.
NHS in England
Nov 2023
P-003114 — South West London Integrated Care Board
Mrs A says the ICB inappropriately allowed her brother to sign a tenancy agreement when he did not have capacity to do so.
NHS in England
Nov 2024
P-003209 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs E complains about the care and treatment the Trust gave to her mother while she was an inpatient between February and March 2022.
NHS in England
Not Upheld
Dec 2024
P-003312 — A practice in the Harlow area
Miss I complains about the care and treatment the organisations gave to her daughter.
NHS in England
Partly Upheld
Jan 2025
P-003597 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs G complains about the way she and her husband were treated in April 2022 when they attended A&E with their foster child. Mrs G says the Trust did not consider the patient history when making a diagnosis and it speculated about how the injury happened.
NHS in England
Jun 2025
P-002651 — Northumbria Healthcare NHS Foundation Trust
Mr R complains about the care provided to his late wife, Mrs R in August 2021. He complains that the Trust did not take Mrs R’s medical history into consideration, and did not recognise, monitor, or escalate Mrs R’s deterioration.
NHS in England
Not Upheld
May 2024
P-003141 — A practice in the East Riding of Yorkshire …
Mrs I complains the Practice did not appropriately assess her son in October 2022.
NHS in England
Nov 2024
LGO / SPSO Decisions (1491)
22-007-258 — Surrey County Council
Summary: Mr X complains about the lack of support from the Council while he was caring for his great aunt, especially during the COVID-19 pandemic period. The Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused to Mr X by the faults …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-018-984 — Surrey County Council
Summary: Mr D complained the Council has failed to provide him with appropriate assistance in securing a care facility for his wife. He also says the Council delayed offering him respite care. We find the Council was at fault as it failed to respond to a request for information regarding …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
NIPSO-18735 — Belfast Health and Social Care Trust
We have asked the Belfast Health and Social Care Trust, in consultation with the other Trusts and health and social care organisations, to agree a uniform approach for assessing all future applications for Continuing Healthcare in Northern Ireland.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
20-010-003 — Hertfordshire County Council
Summary: Mrs X complains the Council has failed to secure the provision in her son, Y’s, education, health and care (EHC) plan.
LGO (Local Government & …
Education
Upheld
Feb 2022
21-013-917 — Trafford Council
Summary: There was fault in the Council’s failure to communicate with Mrs B and Mrs D about a change in care provider. This caused distress to Mrs B and Mrs D. The Council has agreed to apologise to Mrs B and Mrs D and pay them £250.
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
23-013-427 — Suffolk County Council
Summary: Mr X complained the Council has not provided any education or provision set out in the Education Health and Care Plan for his son, Y. The Council has acknowledged fault and offered an appropriate financial remedy for Y’s missed education and provision and the distress caused to the family. …
LGO (Local Government & …
Education
Upheld
Jul 2024
24-000-025 — London Borough of Newham
Summary: We upheld Ms X’s complaint. There was a delay in assessing her son Mr Y’s social care needs and her need for support in her caring role. There was also a delay in agreeing funding for a day centre placement. The outcome and recommendations of assessments were confusing. The …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
23-008-538 — Oxfordshire County Council
Summary: Ms X complained about Oxfordshire County Council, Oxford Health NHS Foundation Trust, and NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. She complained about faults relating to aftercare under section 117 of the Mental Health Act 1983. We have upheld Ms X’s complaints about discharge, assessment, care planning …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-016-919 — Nottingham City Council
Summary: Mr Z complained the Council failed to ensure the care needs of his cousin, Mr X were met when Mr X’s parents left the country. Mr Z says he was forced to provide unpaid care which put him in a difficult position financially as he was unable to work …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-015-945 — Redcar & Cleveland Council
Summary: Mrs X complained that the Council’s delay in referring her mother for Continuing Healthcare (CHC) funding cost her some months of care home charges as well as a private assessment fee. The evidence shows the Council was not responsible for the costs incurred by Mrs X.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2025
24-015-684 — Devon County Council
Summary: Mr X complained the Council has repeatedly failed to follow its policies and procedures which has resulted in a failure to safeguard his daughter, Miss Y. We found
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-014-722 — Cambridgeshire County Council
Summary: Mr X complained the Council delayed completing his care assessment. Mr X says this meant he did not receive suitable support which has impacted his health. The Ombudsman finds the Council at fault which caused injustice. The Ombudsman is satisfied the action taken by the Council has remedied the …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
25-000-452 — Berkley Care Blenheim Limited
Summary: There was fault in the quality of care provided to Mr X’s late grandfather Mr Y by the care home. It failed to carry out a thorough pre-assessment, delayed taking action when Mr Y’s food and fluid intake reduced and failed to properly assess and respond to Mr Y’s …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
25-010-177 — Medway Council
LGO (Local Government & …
Adult Care Services
25-005-861 — Bournemouth, Christchurch and Poole Council
LGO (Local Government & …
Adult Care Services
Upheld
25-016-037 — Dudley Metropolitan Borough Council
LGO (Local Government & …
Adult Care Services
24-007-618 — London Borough of Islington
LGO (Local Government & …
Adult Care Services
Upheld
25-005-749 — London Borough of Hammersmith & Fulham
LGO (Local Government & …
Adult Care Services
Upheld
25-017-108 — Essex County Council
LGO (Local Government & …
Adult Care Services
25-005-438 — Kent County Council
LGO (Local Government & …
Adult Care Services
Upheld
NIPSO-18433 — Northern Health and Social Care Trust
We recommended that the Northern Health & Social Care Trust, either individually or collectively with others, put in place the necessary arrangements for it to appropriately assess all future requests for Continuing Healthcare.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
25-002-493 — Wirral Metropolitan Borough Council
LGO (Local Government & …
Adult Care Services
Upheld
24-022-503 — Derby City Council
LGO (Local Government & …
Adult Care Services
Upheld
21-002-153 — Leicestershire County Council
Summary: Mrs Y complains about the failure of a care provider to ensure a sore on her mother’s leg was appropriately cleaned, dressed and treated. We find fault because there is no evidence to show the care provider properly assessed the sore or sought medical help. This fault creates distress …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
20-014-489 — Hertfordshire County Council
Summary: Ms C complains the Council failed to properly safeguard her mother or provide satisfactory information about funding for care homes. The Council is at fault for failing to carry out safeguarding, assessment, and complaint handling procedures correctly. It is also at fault for failing to properly advise Ms C …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-002-440 — Hertfordshire County Council
Summary: Mr E has complained about the mental health and social care of his sister, Mrs F, by the Council and Trust. We find fault with the mental health and social care of Mrs F but not with her mental health assessment or the Trust’s complaint handling. The Trust and …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-003-768 — London Borough of Redbridge
Summary: Mr B complained the Council delayed meeting his daughters’ assessed needs under the Care Act 2014. He says the Council delayed providing additional support after his daughters stopped attending college. We find the Council was at fault as it delayed responding to Mr B’s requests for additional support. The …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
20-009-729 — London Borough of Wandsworth
Summary: The Council acted with fault when it sent correspondence about Mr Y’s care and support in a format which was not suitable for his needs as a blind person. This caused Mr Y some time and trouble which the Council should apologise and pay £150 for. However, the fault …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-003-092 — Oxfordshire County Council
Summary: The Council was at fault for failing to provide appropriate education and special educational provision to Ms X’s son. It was also at fault for not reviewing Ms X’s son’s Education Health and Care plan within the required timeframe. The Council has agreed to apologise, make a payment for …
LGO (Local Government & …
Education
Upheld
Feb 2022
20-013-288 — Plymouth City Council
Summary: Mr B complained about the way his relative, Mr C, was discharged from psychiatric liaison services on two occasions over one weekend. We found no fault by the Council, Livewell Southwest or the Trust.
LGO (Local Government & …
Adult Care Services
Not Upheld
Feb 2022
19-018-847 — North Lincolnshire Council
Summary: Mr X complained the Council has not provided him with adequate help and support to deal with his care needs. We find the Council was at fault as it failed to pursue an independent assessment to determine if Mr X needed more support. It also did not have an …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-007-811 — Surrey County Council
Summary: Ms C complained the Council has failed to arrange a care support package for her since July 2020. She says this resulted in significant distress, inconvenience and impacted her health, including her mental health. We have found fault with the Council not being able to find a care agency …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-005-184 — Surrey County Council
Summary: There was fault by the Council as its social care assessments contained inaccurate information about the source of a medical diagnosis. This caused Mr X avoidable distress. The Council will apologise, make Mr X a symbolic payment and rectify its records.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-982 — Bournemouth, Christchurch and Poole Council
Summary: We will not investigate this complaint about how the Council completed Mr X’s care plan and provided his transport to his vocational placement. That is because there is not enough evidence of significant injustice to Mr X, or his Shared Lives carers, Mr and Mrs Y.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-015-944 — Wirral Metropolitan Borough Council
Summary: We will not investigate this late complaint about the Council’s decisions relating to Ms Y’s accommodation and how this would be funded. There is not a good reason Ms X did not complain sooner.
LGO (Local Government & …
Adult Care Services
Mar 2022
20-007-526 — Bedford Borough Council
Summary: Ms X complains that she was billed for care that she did not receive and was not supported against financial abuse. There was fault by the Council because it did not include any contingency plan in Ms X’s care plan. The Council agreed a financial remedy to reflect the …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-017-269 — Brighton & Hove City Council
Summary: We will not investigate this complaint about how the Council assessed Ms X's care and support needs. That is because there is insufficient evidence of fault in the Council’s actions to warrant further investigation.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-016-064 — Worcestershire County Council
Summary: We will not investigate this complaint about the Council’s decision not to fund respite care for Mr X. That is because there is insufficient evidence of fault to warrant further investigation.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-013-303 — Stockton-on-Tees Borough Council
Summary: Mr X complained about the Council’s decision not to appoint him as Relevant Person’s Representative for his mother’s Deprivation of Liberty Safeguards authorisation. We have ended the investigation as the appointed Relevant Person’s Representative has approached the Court of Protection and Mr X is party to the proceedings. The …
LGO (Local Government & …
Adult Care Services
Not Upheld
Apr 2022
21-010-549 — London Borough of Hammersmith & Fulham
Summary: Miss X complained about the support the Council provided when she was moving home. Miss X also complained the Council refused to carry out a review of her care plan. Miss X says this has affected her mental and physical health. We find fault with the Council for a …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-007-208 — Hertfordshire County Council
Summary: The Council’s failure to consider the needs and practicalities of the wider family before agreeing that a proposal by the Borough Council would meet Miss X’s disabled child’s needs was fault. The Council has agreed to complete a new assessment.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-002-504 — London Borough of Southwark
Summary: Mrs B complained that the Council converted her bathroom into a shower room in 2018 but the work failed to meet her needs because of inadequate space and the Council has failed to resolve the matter. We found the Council was at fault in that the adaptations completed in …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
20-007-857 — Kent County Council
Summary: Ms C complains the Council has wrongly pursued her for arrears in home support charges and withdrawn her support. The Council is at fault for failing to communicate and assess charges properly and the way in which it reassessed Ms C’s care needs. The Council has agreed to apologise …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-014-878 — Gloucestershire County Council
Summary: Mr and Mrs X and Mrs Y complained about the Council’s decisions about Mrs B’s care and how it considered their views. They also said it wrongly investigated safeguarding concerns about them. We found no fault in how the Council reached its decisions about Mrs B’s capacity and care, …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2022
21-011-043 — City of York Council
Summary: Mr X complained about the Council’s handling of his parents’ home care package and his complaints. There was fault in how the Council failed to review Mr X’s parents’ care plans and did not follow the correct safeguarding process when investigating some concerns about Mr X’s parents. The Council …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
20-000-380b — NHS South West London Clinical Commissioning Group (20 …
Hospital A - Provides specialist treatment for people with severe and complex personality disorders. This hospital is
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
20-000-380a — South London and Maudsley NHS Foundation Trust (20 …
Hospital A Provides specialist treatment for people with severe and complex personality disorders. This hospital is
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
20-000-380 — London Borough of Croydon
Hospital A Provides specialist treatment for people with severe and complex personality disorders. This hospital is
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-008-355 — Staffordshire County Council
Summary: There was fault by two councils in the way they dealt with Mr Y’s care and support arrangements when he was released from prison. This caused avoidable distress. The councils will apologise, make a symbolic payment and review procedures.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-007-683 — Newcastle upon Tyne City Council
Summary: The Council reviewed the amount of Mrs X’s Direct Payment budget to enable her to purchase more overnight stays for her son M after she appealed its initial decision.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2022